Transapical vs. transfemoral aortic valve implantation: Which approach for which patient, from a surgeon's standpoint.

Transcatheter aortic valve implantation (TAVI) has gained increasing acceptance for treating patients with severe aortic stenosis (AS), especially in the presence of a higher risk profile. The procedure is performed a number of ways, however, the two main routes of access are the transfemoral (TF) retrograde approach and the transapical (TA) antegrade approach. At the present time TAVI is indicated in the presence of high risk according to current position statements from the European Society Cardiology and European Association Cardiothoracic Surgery (1). TAVI outcomes in intermediate risk patients, presenting with a logistic EuroSCORE lower than 20% or a Society of Thoracic Surgeons (STS) Score between 4% and 8% are currently being evaluated in prospective randomized trials such as the SURTAVI trial (TF CoreValve™ versus conventional surgery) and PARTNER 2 trial (Edwards SAPIEN-XT™ versus conventional surgery). Despite these advancements in endovascular approaches, conventional surgery remains the standard for many patients and is associated with excellent outcomes. For example, in 2011 a German registry reported an overall mortality to be as low as 3% in 11,500 patients undergoing conventional surgery for aortic valve disease (2). Our common goal is to perform the optimal therapy for an individual patient. This is fundamentally based on a low procedural risk together with immediate functional improvement and good longer term durability. Simplicity and safety will usually lead to good acceptance by the heart team of physicians, mostly cardiologists and cardiac surgeons, to use these approaches. For the individual patient, the overall balance of risks, which cannot be determined by incision length only but rather should prioritize hard endpoints such as mortality and morbidity such as stroke are extremely important. Thus, an objective pre-procedural informative discussion individualized to each patient’s unique risks and potential outcomes is mandatory before choosing between open versus percutaneous options. In this perspective, we highlight the different aspects of choosing the TF versus the TA approach using the best available current literature and propose future prospects for the care of aortic valve disease.